A Patient’s Guide to Psoriatic Arthritis

A Patient’s Guide to Psoriatic Arthritis Share Share on StumbleUpon
Arthritis is an umbrella term that simply describes joint inflammation. There are more than 100 types of arthritis, and they all can have different triggers and characteristics. As such, arthritis is one of the most common chronic conditions, affecting about 54 million Americans or nearly a quarter of all adults. But not all forms of arthritis are created equal. Some, like psoriatic arthritis, are related to immune disorders and can cause a lot of pain and disability. What Is Psoriatic Arthritis?
Psoriatic arthritis is one of several inflammatory forms of arthritis, and it’s related to the common skin disorder psoriasis. Psoriasis is a chronic skin problem that speeds up the life cycle of skin cells. This causes a rapid build-up of cells on the surface of the skin that collect in red, scaly patches. It can be very itchy and painful.
The Arthritis Foundation reports that about 30 percent of people with psoriasis “also develop a form of inflammatory arthritis called psoriatic arthritis.” Like psoriasis, psoriatic arthritis is an autoimmune disorder, meaning that the immune system begins attacking the body’s normal cells, causing inflammation, swelling, pain and eventually damage to the joints.
Dr. David Pugliese, a rheumatologist at Geisinger in Danville, Pennsylvania, says that psoriatic arthritis is one of “a whole host of autoimmune conditions,” that cause joint pain, swelling and other complications. “These conditions can give people arthritis and come with their own host of immune concerns that we need to monitor,” Pugliese says, so it’s important to speak with your doctor if you notice any arthritis-like symptoms in any of your joints. Types of Psoriatic Arthritis
Within psoriatic arthritis, there are three main types. Symmetric psoriatic arthritis affects about 50 percent of patients, and it occurs in joints on both sides of the body. Asymmetric psoriatic arthritis affects about 35 percent of people with psoriatiac arthritis. It’s generally considered the mildest form and tends to affect three or fewer joints. Three other types of psoriatic arthritis make up the rest of cases. Arthritis mutilans occurs in the fingers and toes and is an advanced, deforming type of psoriatic arthritis. Spondylitis impacts the shoulders and neck. And distant interphalangeal predominant psoriatic arthritis impacts the joints at the ends of the fingers. Symptoms
The Arthritis Foundation reports that “most people with psoriatic arthritis have skin symptoms before joint symptoms.” Skin symptoms of psoriasis include: Red patches of raised or inflamed skin. Whitish or silvery scales or plaques on those red patches. Dry skin that cracks or bleeds. Tenderness, itching or burning around the site of the patches. Thick, pitted or ridged nails. Swollen and stiff joints.
But for some people, psoriatic arthritis can develop in the absence of any skin symptoms. “You don’t have to have psoriasis to have psoriatic arthritis,” says Dr. Esther Lipstein-Kresch, chief of rheumatology at ProHEALTH Care in New York. That can sometimes make diagnosis difficult, as the symptoms that accompany psoriatic arthritis may sometimes be similar to those of other forms of inflammatory arthritis.
Common symptoms of psoriatic arthritis include: Swollen, painful joints. Joint stiffness, especially first thing in the morning. Sausage-like swelling along the length of the fingers or toes. Tendon or ligament pain. Skin rashes and pitted nails. Fatigue. Redness and irritation of the eyes and distorted vision.
One of the key distinguishing features of psoriatic arthritis is the development of “sausage-shaped deformity,” Lipstein-Kresch says. “It can happen in the toes and fingers,” and it can be very uncomfortable. This particular type of swelling is less likely to occur in rheumatoid arthritis so it’s often a differentiator in helping your doctor make the right diagnosis.
Another feature of psoriatic arthritis is the development of bone fusions, “where the bones literally fuse together,” Lipstein-Kresch says, a condition called ankylosis. This usually only happens in severe cases that aren’t well managed. “If you’re unlucky enough to fuse your wrist in a really bad position when it’s flexed, you wind up like that the rest of your life. Sometimes people fuse in a neutral position, which is good because if it’s fused, it doesn’t hurt that much and they can still use their hands .” In fact, surgical fusion is sometimes used as a treatment for psoriatic arthritis and other inflammatory arthritis conditions.
While ankyloses can also occur in other inflammatory arthritis conditions, such as rheumatoid arthritis, “psoriatic arthritis generally has more fusion than rheumatoid arthritis. But hopefully in this day and age with all these new biologic medications and other disease-modifying drugs, people wouldn’t get fusion,” Lipstein-Kresch says. Diagnosis
To diagnose a case of psoriatic arthritis, your doctor will conduct a thorough physical exam and take an extensive medical history. Your rheumatologist may also order some blood tests to gauge how much inflammation you have in your body or X-ray images of your symptomatic joints to take a look at what’s going on inside them. You may also have MRIs, ultrasounds or CT scans to look at the extent of damage in your joints.
Although there isn’t a specific blood test currently in use that can say definitively that you have psoriatic arthritis, your rheumatologist will likely order some blood tests to rule out other forms of inflammatory arthritis, such as rheumatoid arthritis. These tests look for an antibody in the blood called the rheumatoid factor. Even if your RF test comes back negative, it doesn’t necessarily mean you don’t have rheumatoid arthritis. Lipstein-Kresch says that about 85 percent of people with rheumatoid arthritis will have a positive RF factor test but “the other 15 percent won’t. Those people have what’s called zero-negative RA.”
Even a positive RF test doesn’t completely rule out a diagnosis of psoriatic arthritis, as the two conditions can coexist, although the National Psoriasis Foundation reports this coexistence of conditions is rare. Nevertheless, it’s important to work with a doctor who has experience in treating arthritis conditions to be sure you’re arriving at the right diagnosis. “Even though we have some tools we use in terms of immunological testing that are helpful, ultimately (the correct diagnosis) still boils down to what the patient looks like on exam and what kind of story they are telling,” Pugliese says. Causes and Risk Factors
Psoriatic arthritis occurs when the body’s immune system misidentifies normal cells as foreign invaders and goes on the attack. The National Psoriasis Foundation reports that skin symptoms are present before the development of joint pain in about 85 percent of cases.
It’s not entirely clear why psoriatic arthritis develops in some people and not others, but genetics are likely part of the answer, as well as environmental factors. People with a family history of either psoriasis or psoriatic arthritis are at higher risk of developing the disorder.
It’s believed that physical trauma or certain environmental factors, such as the introduction of a bacterial or viral infection, could sometimes trigger the immune response that develops into psoriatic arthritis in some people.
Age may also be a risk factor. Although anyone can develop psoriatic arthritis at any age, the Mayo Clinic reports that “it occurs most often in adults between the ages of 30 and 50.” Treatment
Although there’s currently no cure for psoriatic arthritis, the condition can be managed. Patients may be offered a range of different medications, including: Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs reduce inflammation and relieve pain. Some, such as ibuprofen (Advil, Motrin IB, etc.) and naproxen sodium (Aleve) are available over the counter . Your doctor may prescribe stronger NSAIDs to improve symptoms of psoriatic arthritis. Disease-modifying antirheumatic drugs (DMARDs). These drugs stall the progression of psoriatic arthritis and may be used to treat other forms of inflammatory arthritis. Methotrexate (Trexall), leflunomide (Arava) and sulfasalazine (Azulfidine) are three common DMARDs used to treat psoriatic arthritis. Steroids. Powerful anti-inflammatories, steroids such as prednisone (Deltasone, Rayos and Prednisone Intensol) can help bring down a flare-up of psoriatic arthritis or other inflammatory arthritis disorders quickly. Steroids have been around a long time, and “are still excellent medications in terms of cooling things down,” Lipstein-Kresch says. “When you see somebody who is really inflamed and has a lot of pain, can’t sleep and can’t function, the steroids make a tremendous difference very rapidly.” But she says these are generally used sparingly as they can have some harsh side effects when used long-term. Steroids may also be used in combination with other medications to help prime the body’s response for the effects of biologic or other medications. Immunosuppressants. In immune disorders, the body’s natural defense mechanism – the immune system – works overtime and on the wrong targets. By tamping down some of this response, some patients may find some relief from autoimmune conditions such as psoriatic arthritis. Azathioprine (Imuran, Azasan) and cyclosporine (Gengraf, Neoral, Sandimmune) are two immunosuppressant drugs that may be used to treat the condition. Biologics. In the past decade, new medications have emerged to help patients deal with a number of inflammatory arthritis conditions. The NPF reports that these types of drugs are administered by injection or intravenous infusion and are derived from living cells cultured in a lab. Among these are: TNF-alpha inhibitors. These medications target tumor necrosis factor-alpha, an inflammatory substance produced by the body. By inhibiting the production of this substance, that may lead to reduced pain and stiffness and relief from joint swelling. Etanercept (Enbrel), infliximab (Remicade) and adalimumab (Humira), are three examples of this class of drug. Interleukin inhibitors. These drugs selectively target certain cytokines (a kind of protein) involved in inflammatory and immune responses. Examples include secukinumab (Cosentyx), ixekizumab (Taltz), brodalumab (Siliq) and ustekinumab (Stelara). T-Cell inhibitors. T-cells are a kind of white blood cell that create inflammation in psoriatic disease. The drug abatacept (Orencia) may help tamp down some of this response.
Few patients progress to the point of needing surgery, but it can be an option in some cases. In a procedure called synovectomy, your doctor might remove the damaged or diseased tissue from inside the joint. In other cases, a patient may undergo a joint replacement surgery, joint resurfacing or realignment surgery or a bone fusion to relieve pain in a problematic joint. Management
Another hallmark of psoriatic arthritis is frequent flare-ups, or periods when the disease seems worse, followed by periods of fewer symptoms. Managing this ebb and flow is an important part of living with the disease.
Because autoimmune disorders are so closely associated with excessive levels of inflammation in the body, some doctors and patients believe that diet can impact the severity of symptoms . “There are a million and one diets you could find online, and some people come in and tell me every time they have something fried, their arthritis flares up. Or they gave up gluten and feel better, even though there’s no indication that they actually have a gluten sensitivity,” Lipstein-Kresch says. It’s hard to know exactly what might help most in which situation, so it’s best to talk with your doctor about what’s best for you.
In general, it’s believed that foods high in omega-3 fatty acids, such as fish, healthy oils and nuts, could help reduce inflammation in the body. A diet rich in brightly colored fruits and vegetables will also provide lots of antioxidants, which may also help control inflammation. Some studies have connected red meat, high-fat and high-cholesterol foods with increased inflammation, but Lipstein-Kresch says the evidence is “soft” and her best advice is to “eat healthy.”
Exercising regularly is also typically recommended to keep your joints moving as smoothly as possible, retain as much range of motion as possible and to keep your weight in check. When your body is strong, you’ll be better able to cope with your condition. Best Rheumatology Hospitals

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As many of you probably know, cortisol elevates during fasting but not if negative feedback inhibition from exogenous corticosteroids has shut down the adrenal glands. This is no different than the HPG-axis suppression from exogenous androgens, except that one actually needs cortisol to live, while testosterone isnt needed to sustain life.
Also, glucocorticoids elevate both glucose and insulin, and ketosis will suffer greatly if I attempt to fast while Im tapering.
The opioids I will also be tapering off of and if withdrawal is or becomes an issue I have gabapentin, baclofen, and diazepam to lessen the discomfort and to make the transition smoother.
Starting today until March 20, Ill be consuming a single small ketogenic meal after sunset with no water during the day. For the first few days Ill probably be taking 120-180 mg of pseudoephedrine upon waking to help control my appetite, as both opioids and corticosteroids make me constantly hungry.
Starting March 21, at the conclusion of my drug tapers, I will begin fasting with only water, lime juice, electrolytes, black coffee or green tea (if needed), oral hydrocortisone in the morning prior to any anticipated heavy exertion (if any), tianeptine (if needed for mood), a nicotine patch if my energy really starts crashing or the pain from my discs or osteoarthritis becomes too overwhelming, and melatonin at bedtime.
For exercise I will be walking daily once the actual fasting starts. There will likely be no before and after pics, and no daily weigh-in. Im doing this as a gift to my son, who is 4, who needs me to live a very long and healthy life. All previous fasts have had a large aesthetic element but I want this one to be completely selfless. Ill log my weight once per week.
I will not read or watch any news, nor any TV or movies except uplifting documentaries, and the only social media I will be active in is Instagram (pics of my son) and this forum.
At the conclusion (which right now is open-ended) I hope to have healed my body enough that I can begin training again, and most-importantly to try to see life as a gift instead of an affliction. Presently, the only time Im not abjectly miserable is the short period each week I get with my son. It would be nice to be able to see at least some of the joy and wonder and amazement of this world like my son does, instead of seething with sadness, anger, resentment, and regret. I can only barely remember what it felt like to see my life as anything but a tremendous burden. Except for when Im with my son? all of my hope, optimism, inspiration, humor, joy, gratitude, compassion, empathy, and warmth are just gone and no matter how deeply I dig, I just cant find them. Im constantly filled with emptiness so profound that I have stopped loving everyone but my son and have basically abandoned all of my friendships. I used to want to change the world for the better  now I find myself hoping for a nuclear war or Yellowstone eruption. I dont want this any more.
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